The problem of diagnosing gonorrhea is different and in some ways tougher. The part played by medical ignorance or lack of interest, and by technical carelessness or incompetence, is much the same for both diseases. But syphilis can be diagnosed if it is suspected and if the patient can be induced to stay around for the necessary brief interval. Given this much, the worst problem is the occasional biologic false positive; and with time and money which is not to suggest that lack of the second is trivial this, too, can be worked out. In gonorrhea, if there is pus and pain the diagnosis can be made tentatively in a few minutes and confirmed in twenty four to forty eight hours. The main trouble is that, especially in women, there may be neither. The infected woman may have no warning, and if she has had only one sexual partner, and is unaware that he has had others, she may have no basis at all for suspicion. Even when compulsory examinations are made of prostitutes or prisoners the routine tests may fail if the infected area is missed by the examiner's swab. The following remark by two U.S. Public Health workers, Garson and Barton, may sound like a joke but was made in deadly earnest: the most sensitive, practical indicator of gonorrhea in the female is the anterior urethra of a susceptible male.

The paper is dated 1960. There has been progress since then, but the difficulty has not been altogether cleared up. The oldest and still most widely used way of making a tentative or presumptive diagnosis of gonorrhea is to examine a drop of pus under a microscope using a quite ordinary stained slide. The procedure is painless to the patient and can be done, all told, in five minutes. Diagnosis is based on the appearance of typical paired gonococci inside so called pus cells (phagocytes), usually crowding the cells. But the picture is not always typical, and it may be mimicked by somewhat similar bacteria that are not gonococci, making up part of the problem of nongonococcal urethritis. Part of this problem has resulted from the widespread use of antibiotics for other diseases in recent years. So that again we have false negatives and false positives; but both are much more common in gonorrhea than in syphilis.

The usual way of resolving such ambiguity is to make a culture of the gonococcus, in which it can be identified without question. The culture grows out in twenty four hours; another day may be needed for final identifying tests. But these things are easier said than done. To make a culture, the specimen must be sent to a laboratory, and if the doctor is at any distance from an appropriate one, special means must be used to keep the fragile gonococcus alive in transit. The gonococcus requires special culture media and growth conditions. These are, however, within the capacity of any good hospital laboratory. But all the little pitfalls have made the whole procedure a good deal short of perfect.

Nevertheless, in recent years both culture methods for the gonococcus and ways of keeping it alive in transit have been greatly improved, so that errors and missed cases are getting less common. There is little doubt that this diagnostic problem will be solved. In addition to improved culture methods, attempts are being made to improve the specificity of the slide technique with the now widely used fluorescent antibody trick. Antibodies specific for the gonococcus can be produced by injecting them into rabbits, even though the rabbits develop no disease. Such antibodies can be coupled to fluorescent dye. The resulting fluorescent antibody attaches itself specifically to the gonococcus when the two are brought together and identifies it under the special microscope by its greenish fluorescence. The fluorescent antibody technique applied to the gonococcus has so far been most effective when combined with cultures by the newer methods.

Gonorrhea diagnosis has no blood test and would certainly be improved by one, if only because it is easier to take a small blood sample from the arm than to squeeze pus out of the penis or explore the whole vaginal surface with a swab. Blood tests have been devised, and a few have been fairly extensively tested; but up to now none has been accepted. Intensive work is going forward, however, although only in a few laboratories; and success may be around the proverbial corner.